Rene A. Cervantes-Castañeda

Biological response modifier therapy for refractory childhood uveitis

Purpose: To evaluate the use of biological response modifiers (BRM) in the treatment of refractory childhood uveitis. Design: Retrospective non-comparative case series of pediatric patients with uveitis treated with BRM. Participants: 23 pediatric patients. Methods: All children (18 years or younger) who received a BRM were assessed for visual changes, time to control inflammation, and any associated adverse side effects. Thirteen patients were treated with infliximab, five with adalimumab, and five with daclizumab. All patients had bilateral eye involvement. Diagnoses of the participants included juvenile idiopathic arthritis, keratouveitis, sarcoid panuveitis, Adamantiades–Behcets disease, and idiopathic panuveitis. Main outcome measures: Inflammation and visual acuity. Results: In the infliximab group 16 of 26 eyes (62%), and 10 of 13 patients (77%) demonstrated an improvement in visual acuity. Twenty of 26 eyes (77%) demonstrated an improvement in the degree of inflammation. In the adalimumab group, four of 10 eyes (40%) demonstrated an improvement in visual acuity, with five of 10 eyes (50%) demonstrating an improvement in inflammation. Four of 10 eyes (40%) in the daclizumab group demonstrated an improvement in vision with eight of 10 eyes (80%) demonstrating an improvement in inflammation. Conclusion: BRM appear to be safe to use in children, and represent a useful therapeutic adjunctive drug group for treating recalcitrant childhood uveitides.

Intravitreal triamcinolone acetonide injection for treatment of refractory diabetic macular edema: a systematic review

OBJECTIVE To compare intravitreal triamcinolone acetonide (IVTA) injection versus no treatment or sub-Tenon triamcinolone acetonide (STTA) injection in improving visual acuity (VA) of patients with refractory diabetic macular edema (DME; unresponsive to focal laser therapy). CLINICAL RELEVANCE Diabetic macular edema is the leading cause of visual loss in diabetic retinopathy. Laser therapy has been the standard of care for patients with persistent or progressive disease. More recently, it has been suggested that IVTA injection may improve VA. METHODS AND LITERATURE REVIEWED: The following databases were searched: Medline (1950-September Week 2 2008), The Cochrane Library (Issue 3, 2008), and the TRIP Database (up to September 1, 2008), using no language or other limits. Randomized controlled trials were included that consisted of patients with refractory DME, those comparing IVTA injection with no treatment or STTA injection, those reporting VA outcomes, and those having a minimum follow-up of 3 months. RESULTS In the 4 randomized clinical trials comparing IVTA injection with placebo or no treatment, IVTA injection demonstrated greater improvement in VA at 3 months, but the benefit was no longer significant at 6 months. Those who received IVTA injection had significantly higher IOP at 3 months and at 6 months. In the 2 randomized clinical trials comparing IVTA injection with STTA injection, IVTA injection demonstrated greater improvement in VA at 3 months, but not at 6 months. Intravitreal triamcinolone acetonide injection demonstrated no difference in IOP at 3 months or at 6 months. CONCLUSIONS Intravitreal triamcinolone acetonide injection is effective in improving VA in patients with refractory DME in the short-term, but the benefits do not seem to persist in the long-term. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The characteristic features of optical coherence tomography in posterior uveitis

Aim: To describe the different retinal morphological characteristics that can present on optical coherence topography (OCT) in a spectrum of uveitic diseases. Methods: We reviewed the literature and our own OCT image archive for characteristic features that may be suggestive of a particular disease process. Results: OCT demonstrates a variety of characteristic morphological changes, some that may point towards a specific disease process. We describe the various forms of macular oedema found in uveitis as well as OCT features typically found in multifocal choroiditis, serpiginous chorioretinitis, toxoplasma chorioretinitis, Vogt–Koyanagi–Harada, sympathetic ophthalmia and the vitreomacular traction syndrome. Conclusion: Ophthalmologists should be aware of the variety of retinal morphological characteristics that can present on OCT in uveitic disease. Recognition may aid in the diagnostic process, which is complementary to conventional fundal photography and fluorescein angiography. This can facilitate earlier diagnosis and, more importantly, the initiation of specific treatment.

Mycophenolate Mofetil Therapy for Sarcoidosis-Associated Uveitis

Purpose: To evaluate the control of ocular inflammation and the steroid sparing effect in patients with sarcoidosis-associated uveitis treated with mycophenolate mofetil (MMF). Methods: Retrospective case series. All patients with a diagnosis of sarcoidosis-associated uveitis that were treated with MMF between 2005 and 2007 were identified. The dose and duration of MMF therapy and side effects were recorded. Results: Seven patients (14 eyes) with sarcoidosis-associated uveitis were treated with MMF. The mean duration of treatment was 10 ± 4.7 months and the average time to control uveitis was 6.7 weeks. The flare-up rate was 51.5 per 100 person-years follow-up. The best-corrected mean logMAR VA revealed improvement in all 14 eyes. The efficacy of MMF in keeping disease activity under control was maintained in 6 patients. Conclusion: These data suggest that MMF is effective in controlling sarcoidosis-related ocular inflammation, has a corticosteroid sparing effect and a manageable side-effect profile.

Intravitreal bevacizumab in refractory uveitic macular edema: one-year follow-up.

Purpose Uveitis is a major cause of ocular morbidity in developed countries. It has been demonstrated that macular edema is a significant cause of decreased visual acuity and macular edema in these patients. In this article, we evaluate the long-term outcome of intravitreal bevacizumab in the treatment of refractory uveitic macular edema. Methods In this retrospective, noncomparative, interventional case series, uveitic patients with macular edema who were refractory to conventional therapy and who were treated with intravitreal bevacizumab were identified and assessed. Best-corrected visual acuity and optical coherence tomography central macular thickness measurements were collected and analyzed with correlative statistical analysis, including the use of Student paired t-test, Kaplan-Meier, and linear regression analysis. Results Twenty-nine eyes of 27 patients with diverse uveitic etiologies were analyzed and followed up at 1 year. Thirteen patients received a single intravitreal bevacizumab injection. Six patients required a second intravitreal bevacizumab injection, while 10 patients received combination therapy of intravitreal bevacizumab and triamcinolone acetonide. Baseline mean logMAR visual acuity was −0.59. At 1 year, the mean logMAR visual acuity was −0.42± 0.36 (p=0.0045). Baseline mean central macular thickness was 383.66 μm. At 1 year, the mean thickness was 294.32±110.87 (p=0.0007). Conclusions Intravitreal bevacizumab is a useful and therapeutically beneficial agent in the treatment of refractory uveitic macular edema. Some patients will require adjunctive intravitreal bevacizumab injections or the use of combination therapy with intravitreal triamcinolone acetonide.

Outcomes of cataract surgery in children with chronic uveitis

PURPOSE: To evaluate the outcomes of cataract surgery in children with chronic uveitis. SETTING: Massachusetts Eye Research and Surgery Institution, Boston, Massachusetts, USA. METHODS: This retrospective chart review was of patients younger than 17 years with a history of uveitis who had cataract surgery before June 2004. RESULTS: Thirty‐four children (41 eyes) were identified. The mean age of the 10 boys and 24 girls was 9.8 years (range 4 to 17 years) and the mean total follow‐up, 4.1 years (range 0.3 to 15.7 years). Twenty‐one children had juvenile idiopathic arthritis–associated uveitis, 7 had pars planitis, and 6 had other conditions. Sixteen patients had concomitant posterior segment pathology, 25 received perioperative immunomodulatory therapy, and 13 had intraocular lens (IOL) implantation. The postoperative best corrected visual acuity improved in 35 of 41 eyes; 31 eyes had an improvement of 3.6 lines at 1 year. Most patients (92%) improved after IOL implantation. Most patients (88%) who received immunomodulatory therapy attained better vision, but this was not statistically significant compared with those who did not (P = .47). Similarly, there was no statistically significant difference between those with posterior pathology and those without. At the end of the analysis (1 year), the cumulative probability of improvement in visual acuity in 41 eyes reached 0.91. CONCLUSION: In most cases, and with optimum control of intraocular inflammation, cataract surgery improved the visual outcome in children with chronic uveitis. Intraocular lens implantation was well tolerated in most cases, which may result in optimal vision.

Combined therapy of cyclosporine A and mycophenolate mofetil for the treatment of birdshot retinochoroidopathy: a 12-month follow-up

Purpose To retrospectively report a 12-month follow up for combined therapy with systemic cyclosporine A (CSA) and mycophenolate mofetil (MM) in treatment of patients with birdshot retinochoroidopathy (BSRC). Participants Ninety-eight eyes of patients who received CSA and MM for the treatment of BSRC were included in the study. Methods All patients were followed for at least five visits during the study, or until treatment failure, or loss of follow-up. Clinical data were analysed using a Student paired t-test, Wilcoxon signed-rank test, McNemars test, and Kaplan -Meier survival curve. Side effects related to therapy were also recorded. Main outcome measures included best-corrected logarithm of the minimum angle of resolution visual acuity, vitreous inflammation, fluorescein angiography pathologic features, and electroretinogram recordings. Results Vitreous inflammation scores at baseline and at 1 year were statistically significantly reduced in both eyes (p<0.001; p=0.001). The presence of angiographic leakage at the 1-year follow-up was significantly reduced (p=0.004). However, the presence of cystoid macular oedema (p=0.32) and comparison of electroretinogram 30-Hz amplitude revealed no significant reduction between baseline and 1-year values for either eye (p=0.61, p=0.87); nonetheless, 30-Hz implicit times were statistically significantly shorter at the end of follow-up for both eyes (p<0.001, p=0.035). Thirty-one patients (67.4%) achieved inflammation control at the 1-year endpoint. Side effects were transient, and resolved after lowering or withholding IMT for a few weeks in the majority of patients. Conclusions These results suggest that combined IMT with CSA and MM for BSRC is well tolerated and associated with long-term control of inflammation.

Biologic Response Modifier Therapy for Psoriatic Ocular Inflammatory Disease

Purpose: To evaluate the efficacy and safety of biologic response modifiers (BRMs) in the treatment of patients with psoriatic ocular inflammatory disease. Methods: The records of 8 patients diagnosed with psoriatic ocular inflammatory disease who received adalimumab or infliximab were reviewed. Main outcome measures were control of intraocular inflammation, visual acuities, and adverse effects of therapy. Results: The mean patient age was 53 ± 15 years. Three patients had psoriatic panuveitis, 3 had psoriatic scleritis, and 2 patients had psoriatic anterior uveitis. The ocular inflammatory disease was bilateral in 7 patients. Four patients received adalimumab, and 4 received infliximab. Average time of therapy was 6.1 ± 4.7 months. Six patients were treated concurrently with methotrexate. With respect to visual acuity, 2 patients demonstrated improvement, 2 patients demonstrated deterioration, and 4 patients remained stable. Seven patients achieved remission of their ocular inflammation. Conclusions: BMRs can be a useful adjunctive therapy for psoriatic ocular inflammatory disease.

Patterns of Exacerbations of Chronic Non-Infectious Uveitis in Pregnancy and Puerperium

Purpose: To determine patterns of exacerbations of recurrent non-infectious uveitis during pregnancy and puerperium. Design: Retrospective cohort study. Methods: The medical records of 32 women with a history of chronic non-infectious uveitis, who were pregnant during their follow-up at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary, from 1983 through 2003, were reviewed. The uveitis relapse rate during pregnancy was compared to the relapse rate during pregnancy-free periods in these women and to the relapse rate in a control group of women of childbearing age with recurrent non-infectious uveitis. Results: Among the 32 women who were pregnant during follow-up (40 pregnancies), the rate of flare-ups during pregnancy (1.0 recurrence per year) was lower than that observed during non-pregnant periods (2.4 per year; p < 0.001) and lower than that observed in the non-pregnant control group (3.1 per year; p < 0.001). Flare-ups were most frequent in the first trimester of pregnancy and decreased markedly in the second and third trimesters (2.3, 0.5, and 0.4 recurrences per year, respectively; p < 0.001). Conclusions: Pregnancy is associated with lower numbers of flare-ups of non-infectious uveitis compared to the non-pregnant state. If flare-ups do occur during pregnancy, they happen predominantly in the first trimester.

Cataract surgery in children with juvenile idiopathic arthritis associated uveitis.

Formerly known as juvenile rheumatoid arthritis, juvenile idiopathic arthritis (JIA) is a chronic idiopathic arthritis that occurs in children under 16 years of age. It can be classified by type of onset into oligoarticular, polyarticular, and systemic JIA, each of these categories having their own clinical characteristics. The estimated prevalence of JIA in the United States is about 113/100,000 children. It is much more common in girls (70% to 75%) than in boys, and there is no observed predilection for race. JIA is the systemic disease most commonly associated with childhood uveitis compromising 40% of all childhood uveitis cases and 70% of the anterior uveitis group. The cause of the uveitis and arthritis in JIA is unknown. Genetic factors are associated with JIA and the development of uveitis. HLA-DR5 is associated with uveitis in children with oligoarticular JIA. On the other hand, HLA-DR1 and HLA-DR4 have been negatively associated with uveitis. Young females affected by monoarticular and pauciarticular JIA with a positive antinuclear antibody test and HLA-DR5 have the highest risk of complications such as cataract, band keratopathy, glaucoma, and chronic hypotony. Early diagnosis and aggressive treatment to prevent ocular complications of the disease are the primary goals in the management of uveitis in children with JIA.